Overview: What are gallstones?
Gallstones come in a wide variety of shapes and sizes: Sometimes they are as tiny as grains of sand, but in extreme cases they can be as big as a potato. Sometimes they are brown, sometimes yellow, sometimes gray or black. However, all gallstones have one thing in common: they develop as hard deposits (concretions) of bile.
Bile (also known as bile or bile for short) is a secretion produced in the liver to aid digestion. Bile helps to break down fats in the intestine. To get from the liver to the intestine, it first flows through small channels (bile ducts or bile passages) into the gallbladder. This is where the liquid is thickened and stored. When the digestive process begins, the gallbladder contracts and pushes the required bile secretion through the bile ducts into the small intestine.
Gallstones(choleliths) can form either in the gallbladder or in the bile ducts and cause health problems in both cases. The long technical terms for this are easier to understand if you know: the syllable “-iasis” at the end of a medical term means disease, and the syllable “-lithiasis” stands for a condition caused by stones:
- Cholelithiasis is an umbrella term for the presence of gallstones. It can be a single stone or several. Gallstones that have formed in the gallbladder can also “migrate” and become lodged in the bile ducts.
- Gallstones in the gallbladder are known as cholecystolithiasis.
- Gallstones in the bile ducts are called cholangiolithiasis.
- A bile duct coming from the liver meets a bile duct coming from the gallbladder in the abdomen; both form the so-called common bile duct (ductus choledochus). This is the last section that the bile travels on its way to the small intestine. If there are gallstones in this approximately ten centimeter long section, this is known as choledocholithiasis.
Gallstones are widespread: In Europe, ten to 15 percent of all people develop such deposits in the course of their lives. In Switzerland, this corresponds to 870,000 to 1.3 million people affected, a clear majority of whom are women. More than 70 percent of these people do not notice their gallstones because they do not cause any symptoms. However, in around a quarter of those affected, the stones become noticeable at some point and require medical treatment.
Causes: Why do gallstones develop?
Bile consists mainly of water. Only a small proportion contains other substances such as cholesterol, bile acid and the bile pigment bilirubin. As long as these substances are in a balanced ratio in the bile, they remain dissolved in the water. However, if an imbalance develops, crystals can form in the form of gallstones. It is not known exactly how and why this happens in individual cases.
However, doctors are aware of a number of factors that promote the development of gallstones. Six of these risk factors are known in medicine as the six F rule: “fat, female, fair, forty, fertile, family”.
- The word “fat” refers to severe overweight and a high-fat diet.
- The word “female” expresses the fact that women are two to three times more likely to develop gallstones than men.
- The word “fair” (blonde) indicates that a light skin type is more likely to be affected than people with darker skin.
- The word “forty” is intended to express that the risk increases over the age of 40, even though gallstones can occur in all age groups.
- The word “fertile” means that pregnancy is a risk factor.
- The word “family” indicates a familial predisposition to gallstones, as studies have shown that genetic causes also appear to play a role in their development.
If several of these risk factors come together, the likelihood of developing gallstones increases. For example, they occur in 40 percent of all women over the age of 60. However, this does not mean that they necessarily cause them discomfort. However, gallstones can also occur without the above-mentioned risk factors.
Symptoms: How do gallstones become noticeable?
Around three quarters of all gallstones do not cause any symptoms and are therefore described as “asymptomatic” (without symptoms). In other cases, when the gallstones become noticeable, the symptoms often start after eating, often late in the evening or at night. They usually last longer than 15 minutes and can last up to several hours.
The symptoms caused by gallstones often manifest themselves in the form of pain that cannot be precisely localized. For example, it can occur as a feeling of fullness in the gastrointestinal tract, as cramp-like pain or colic, but also as a feeling of pressure in the so-called upper abdomen (epigastrium); this is the area between the ribcage and the navel. In special cases, however, far more painful consequences are also possible:
Pain with cholecystitis
Gallstones can lead to an acute inflammation of the gallbladder called cholecystitis (or cholecystitis). Possible symptoms include pain in the right upper abdomen, which is often worse when inhaling, as well as loss of appetite, nausea and fever.
Pain with cholangitis
If bile cannot flow freely because gallstones block the bile ducts, these can become inflamed. This type of inflammation is called cholangitis. Its symptoms are pain in the right upper abdomen, which can extend to the shoulder or back, sometimes accompanied by fever, nausea or vomiting.
Pain with biliary colic
If gallstones block the outflow of bile from the gallbladder, this can lead to biliary colic. In this case, the gallbladder contracts, usually in episodes, which leads to severe cramp-like pain.
Pain with pancreatitis
Shortly before the bile flows into the small intestine, the bile duct merges with another duct that comes from the pancreas. If gallstones get stuck in this last part, the pancreatic juice that is supposed to flow into the intestine accumulates. The backlog can reach the pancreas and release enzymes that trigger inflammation – acute pancreatitis. This usually causes severe and sudden pain in the upper abdomen, which is often felt as drilling or dull. Nausea and vomiting may also occur.
If gallstones prevent bile from flowing into the small intestine over a long period of time, another symptom may appear: a yellowish discoloration of the skin and the white areas around the eyes. This phenomenon is called jaundice or icterus. Other signs of a build-up of bile can be dark urine and light-colored stools. These color changes are a result of the bile pigment bilirubin. Its proportion in the blood increases when blocking gallstones prevent the bile from reaching the small intestine and being excreted from here.
Diagnosis: How can you recognize gallstones?
If gallstones are suspected, your doctor will first carefully palpate your abdomen. The exact diagnosis is then made using more precise examination methods:
- Ultrasound examination (sonography) is the most important method for detecting gallstones. It is considered to be very reliable, but should be in the hands of specialists with a lot of experience so that nothing is overlooked. This is because it is often small or very small gallstones that cause discomfort.
- Special ultrasound devices also enable endosonographyin which the bile ducts are visualized from the inside. This is done using an endoscope – a thin tube with a light source, a camera and, in this case, an ultrasound probe at the tip. If the endoscope is pushed through the mouth and stomach to the small intestine, the bile ducts can be visualized here.
- A blood test can provide important additional information. If there is an increase in certain enzymes in the blood (e.g. gamma-GT), this is an indication of a disease of the bile ducts. Inflammation of the gallbladder can also become noticeable in the blood in the form of increased inflammation values. This includes, for example, an increased number of white blood cells (leukocytes).
- There is a special imaging procedure for the detection of gallstones MRI examination (magnetic resonance imaging, also known as magnetic resonance tomography). As it not only images the bile ducts, but also the pancreatic ducts, this method is known as magnetic resonance cholangiopancreatography. This term is better remembered as an abbreviated form: MRCP
- An examination procedure with X-rays is the ERCP (endoscopic retrograde cholangiopancreatography). An endoscope is used for this. It is carefully moved via the mouth and stomach towards the intestine. At the point where the bile duct joins the small intestine, a contrast medium is used during the X-ray examination to show possible narrowing of the bile ducts and pancreatic ducts. Smaller procedures can also be performed with the help of small forceps at the tip of the endoscope; for example, a gallstone can be removed from a bile duct.
Treatment: How are gallstones treated?
If gallstones do not cause any symptoms, they usually do not need to be treated. If they cause problems, for example acute pain in the case of biliary colic, antispasmodic or pain-relieving medication can help in the short term. In addition, those affected should reduce their oral diet after the onset of biliary colic. If the gallbladder is inflamed, surgery is indicated in addition to painkillers.
Removal of the gallbladder
In cases of complaints caused by gallstones, it is recommended to remove the gallbladder. This is done during an operation called a cholecystectomy. With around 16,700 operations a year, this procedure is one of the most common operations in Switzerland.
Laparoscopic cholecystectomy
The gallbladder is usually removed laparoscopically during a cholecystectomy, i.e. using so-called keyhole surgery. Only minimal incisions are required, through which the surgeon inserts a camera and small instruments into the abdominal cavity. After the removal of the gallbladder, the production of bile in the liver is not stopped – the fluid is now stored in the bile ducts. Even after removal of the gallbladder, a life without significant restrictions is usually possible.
Medication
For patients who do not qualify for an operation (e.g. the risk of anesthesia is increased), there is the possibility of removing them with the help of medication. The medicine (ursodeoxycholic acid, UDCA for short) must be taken over a longer period of time until the stones have gradually dissolved. However, the risk of gallstones recurring after this treatment is high.
Gallstones: shock wave therapy
If surgical removal of the gallbladder is not possible, another method of getting rid of gallstones is shock wave therapy(lithotripsy). The stones are shattered with the help of high-energy ultrasound. The body gets rid of the fragments by flushing them out via the bile ducts. Even after this therapy, there is an increased risk of gallstones forming again, as well as choledocholithiasis and pancreatitis.
If you experience pain in the abdominal area for a long time or frequently, do not hesitate to consult your doctor as soon as possible. If gallstones are suspected as the cause of your symptoms, it is advisable to seek advice from a hospital that has many years of experience in the assessment and treatment of gallstones.
Prevention: Can gallstones be prevented?
Even though genetic causes can play a role in the development of gallstones, there are some ways to reduce the risk of gallstones forming:
- Avoid being overweight.
- Make sure you exercise regularly and sufficiently.
- Eat plenty of fruit, vegetables, salad and wholegrain products.
- Make sure you only consume a small amount of sugary drinks and food.
If you take these points to heart, you will not only reduce the risk of complaints caused by gallstones: you will also support your health comprehensively and can thus help to prevent other diseases.